MANAGEMENT OF DIABETES DURING FASTING AND

FEASTING IN INDIA

REVIEW ARTICLE: JOURNAL OF THE ASSOCIATION OF

PHYSICIANS OF INDIA.-PUBLISHED ON SEPTEMBER 2019

PRESENTED BY:- DR.M.JATTADHARDNB 1ST YEAR RESIDENT GENERAL MEDICINE

MODERATOR: DR.ASHUTHOSH OJHA,CONSULTANT

GENERAL MEDICINE.DR.B.BHARANI.CONSULTANT

ENDOCRINOLOGY.

OBJECTIVES:

• Abstract• Introduction• Methodology• Types of fasting• Challenges• Breaking of fast• Patient monitoring• Diabetes complications• Management of diabetes during fasting and feasting• Management of T1DM and T2DM• Special populations• Conclusion • Executive summary

ABSTRACT:

• Fasting and feasting are the integral part of many religions and cultures. As the amount of food and fluid in take are markedly altered during these phases, patients with diabetes are prone to higher risk of complications.

• Even though several guidelines for fasting and feasting are available, Indian specific recommendations are the need of the hour, because of the distinct dietary habits and diet content(high carbohydrate) of Indians.

• To fill this void, the current guidelines have been developed by experts from India who extensively reviewed the literature, shared their practical knowledge and ultimately arrived at a consensus.

INTRODUCTION:• The international diabetes federation(IDF) in their current

report states that approximately 73 million people with diabetes are living in India.

• Data from multi- country studies, including India, report that arround 79-94% of muslims with type-2 diabetes mellitus undergo fasting during Ramadan for atleast 15days.

• It is evident that people with type-2 diabetes observe fasting or feasting during various festivals in India, hence management of diabetes during these phases becomes extremely important.

Methodology:

• In the process of literature search, various MeSH keywords including fasting, feasting, hypoglycemia, hyperglycemia, Ramadan, diabetes, etc have been used.

• Excisting guidelines, meta-analysis, systematic reviews, randomized controlled trials, non-RCTs, and key articles related to diabetes management were reviewed.

Types of fasting:• Hindu fasts and feasts:

Fasts:- karva chauth, Guru poornima,ekhadasi, Pradhosha, Navratras.Feasts:- Diwali, Pongal, Dasera, Holi.

• Islamic fasts and feasts:Fasts:- sawn, is abstaining from eating and drinking during day light

hours. Ramadan, Ifthar, Suhur, Eid-ul-fitr.• Jain fasts and feasts:

Paryushan, Ratri bhojan tyag.• Buddhists fasts and feasts:

Vassa or Buddhist lent is the fast and feast observed by buddhists for 3 lunar months every year in the rainy season. Fast for 12hrs(noon to mid night) and feast for 12hrs(mid night to noon).

• Christians, Sikhs, Parsis.

Risk population:

• It is important to stratify paitents into different risk categories according to their comorbid status, continued medication, health status, etc…

Challenges: -Hyperglycemia, Hypoglycemia, Dehydration, DKA, Microvascular and

marcovascular problems may create challenges.-Taking Insulin and other OADs without any dose adjustments during fasting

period increases the risk of complications.-Inspite of ill health, some people do fast .-During fasting, alteration of physical and mental health,especially in elder

and comorbid patients with diabetes,places them at great risk of complications.

- Due to irregular food habits some patients may miss their usual medication dose.

- Poor monitoring of diabetes complications,and blood sugar,specifically in rural areas pose a significant risk.

Breaking of fast:

Literature and guidelines advocate that patients with diabetes should break their fast if:

• Blood glucose level is <70 mg/dl(3.9mmol/l)or >300mg/dl(16.7mmol/l).

• Symptoms of hypoglycemia, hyperglycemia, dehydration or acute illness develop

• Patients taking insulin,or on any other OHA,if the blood glucose levels fall < 70mg/dl in the first few hours after the start of fast.

• Patients suddenly feeling unwell.• Dramatic changes in their blood glucose profile during

fasting period.

Patient monitoring

Patients who are at higher risk of diabetes associated complications,should be monitored regularly.

• Those on insulin therapy• Ill and comorbid patients• Patients treated with OADs especially

metformin,glibenclamide• Patients with T1DM.

DIABETES COMPLICATIONS:

The population based epidemiology of diabetes in Ramadan(EPIDAR) study report that fasting increases the risk of severe hypoglycemia(defined as hospitalistion due to hypoglycemia) by 4.7-fold in patients with T1DM(from 3 to 14 events/100 people /month) and 7.5-fold in patients with T2DM(from 0.4 to 3 events/100 people/month).

There was a 5-fold increase in incidence of severe hyperglycemia (requiring hospitalisation in T2DM (from 1 to 5 events/100 people/month) and an approximately 3-fold increase in T1DM(5-17 events/100 people/month) as reported by extensive EPIDAR study.

Management of diabetes during fasting and feasting:

• Pre-fast medical assesment/counselling • Structured diabetes education:

The health care professionals should be sufficiently trained to deliver a structured patient education to patients and family members inclusive of blood glucose monitoring, nutritional advice, exercise advice, dosage, timing of medications, their adjustments, symptoms of complications and their management, and knowing when to break the fast in order to reduce the complications.

Management of T1DM:• Patients with T1DM have been considered as a

very high risk group for fasting in various guidelines and literature.

• Evidence suggests that fasting for 25hrs is safe and can be observed by patients with T1DM.

• The south Asian consensus guideline on insulin use during Ramadan advocates that once or twice daily injections of intermediate or long-acting insulin along with pre-meal rapid-acting insulin can be safely used in patients during fasting.

Management of T2DM:• Non-pharmacological management:

life style modification, physical activity, and yoga.• Nutrition plan:Pre-fast meal should be composed of complex carbohydrates with

low glycemic index and proteins such that it can provide enough slow release calories to take care of the fasting period;unprocessed cereals,fruits,nuts,and lentils can be used in the pre-fast meals.Incontrast post-fast meal should be composed of simple carbohydrates like bread ,cereals,rice,mango,pasta and artificial syrup.

Adequate water and fluids must be taken prior to the fast

especially in cases where fluid intake will be restricted through out the day.

pharmo

• Pharmacological management:

• Metformin:metformin can be safely used during fasting periods due to

minimal chances of hypoglycemia. However patients who are taking metformin during lunch time

should omit the dose ,during day fasting, morning dose can be taken as usual but, a large dose should be taken after breaking the fast to avoid hyperglycemia.

• Sulfonylureas: Evidence advocate that gliclazide, among all the SUs, is

associated with good glycemic control with lesser hyperglycemia.A systematic review and network meta analysis of RCTs

reports that gliclazide compared to other SUs, is associated with lower risk of all cause and cardiovascular related mortality in patients with T2DM.

Gliclazide is safest during fasting periods in Indian Patients.Moreover, Glibenclamide should be avoided and other SUs,

should be used with caution during fasting period.

• DPP-4 inhibitors: vildagliptin and sitagliptin are the mostly used DPP-4 inhibitors in the studies during the fasting period.

• SGLT-2 inhibitors:They can be safely used in the treatment af T2DM

during fasting due to low risk of hypoglycemia;however fasting for long period without taking fluids may aggravate risk of hypotension and dehydration associated with these agents.

Their usage should be restricted in patients at high risk of complications including elderly patients,patients with renal impairment,hypotension individuals,and those at risk of dehydration or taking diuretics.

• Thiazolidonediones:Thiazolidonediones(pioglitazone) may used during

fasting period due to low risk of hypoglycemia;however weight gain is a concern.

• Alpha-glucosidase inhibitors:Acarbose, miglitol,and voglibose can be safely used

without any dose adjustment.However ineffectiveness as monotheraphy and concerns regarding the GI sideeffects reduces their applicability in T2DM patients during fasting period

• GLP-1 RECEPTOR AGONISTS: Liraglutide,exanatide,albiglutide,lixisenatide and

dulaglutide . Important advantage associated with these agents is low risk of hypoglycemia and weight loss.

GI upset was common with the usage of liraglutide.

• Insulins:many T2DM patients use insulin as a

treatment option. However, the higher risk of hypoglycemia and multiple injections reduces its usage in T2DM patients especially during the fasting period.

insulin analogues (basal,prandial and premix) are generally recommended over regular human insulin due to a number of advantages ,including lower rates of hypoglycemia.

Special populations:

• Pregnant women,children, elderly, patients with comorbidities and poorly controled T1DM are group of patients requiring special attention during fasting and feasting period.

• Pregnant women with diabetes are generally are managed with insulin preparations during the fasting period.

• Elderly patients who wish to fast for a prolonged period are at increased risk of hypoglycemia, hyperglycemia and metabolic decompensation including hyperosmolar coma,DKA, Dehydration and thrombosis.

• SGLT2 inhibitors should not be used in this group due to risk of dehydration and volume contraction.

Conclusion:

The panel concludes that appropriate lifestyle modifications including physical activity, nutrition plan, prefast counseling and structured diabetes education plan along with proper treatment dose adjustment or modification are important to ensure a safe fasting or feasting period.

Executive summary:

MY VIEWS:

• Patients with diabetes and undergoing fasting should share their experience related to physical and mental health, symptoms, complications, steps taken to prevent complication and about their quality of life during the fasting period.

• Patients who are using the insulin should practice the SMBG monitoring system and communicate their readings to physicians regularly inorder to reduce the risk of complications.

Thank you